Project Information Form. Date of Submission: Zoning District: Tax Map # (s): Project Size (Acres): City: State: Zip: City: State: Zip:

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1 Project Information Project Type: Building Permit Project Information Form Date of Submission: Zoning District: Tax Map # (s): Project Size (Acres): Project Name: Project Project Description: Village of Saranac Lake Community Development Department 3 Main Street Saranac Lake, NY Phone (518) Fax (518) Property Owner Name(s): Applicant Name (if different): City: State: Zip: City: State: Zip: Contact Person: Cellular: Fax: City: State: Zip: Application Completeness (For Office Use Only) Project Information Form Contractor Information Form Project Data and Narrative Form Sketch Plan Occupancy and Size Form Construction Checklist Property Affidavit Form Agent Authorization Form (if applicable) Insurance Information Form Workers Compensation Documentation Liability Insurance Documentation Two (2) Sets of Completed Construction Data & Plans (including design professional seal if applicable) Application Fee: $ The enclosed application was reviewed and is deemed complete. Application Received Date Staff Reviewer Signature Date Assigned Project Number 1 of 11 v

2 Contractor Information Form Instructions: Please provide information for each contractor and design professional that will perform work for the proposed project. Check each type of contractor that will be used for the project and complete the information for each. Note: New York State Education Law Sections 7307 & 7209 require the seal and signature of a licensed architect or professional engineer to be affixed to all plans submitted, except residential buildings under 1,500 square feet of living area, or to alterations costing less than $20,000. Contractor/ Licensed Design Professional Information Licensed Design Professional Name: General Contractor (if different than applicant): City: State: Zip: City: State: Zip: License #: Electrical Contractor: Plumbing Contractor: City: State: Zip: State: State: Zip: HVAC Contractor Other Contractor or Professional City: State: Zip: City: State: Zip: Instructions: All electrical work must be inspected by a third-party electrical inspection agency approved by the Village of Saranac Lake. Indicate which qualified agency will be used. Electrical Inspection Information The Inspector 7063 State Route 374 Chateaugay, NY Local Tel: (518) Toll Free Tel: The project does not involve any electrical work. New York Board of Fire Underwriters Main Customer Service Center 202 Arterial Rd Syracuse, NY Toll Free Tel: of 11 v

3 Project Data and Narrative Form Instructions: Describe the proposed project. Include an approximate schedule for construction and whether the project will be completed in phases. The cost of construction should include the total cost of labor and materials for all work to be completed under the building permit. Indicate what any new building will be used for. For existing buildings or spaces, indicate its current or most recent use. Narrative Cost of Construction: Proposed Occupancy: Current Occupancy (for existing building): Instructions: Refer to Chart 3.1 Planning Areas and Sub-Areas by Dimensional Standards on page 57 of the Land Use Code in order to complete the Allowed/ Required column on the Project Data Table below. Complete the Requested Relief column for each standard from which a variance is requested. Project Data Table Project is the renovation or alteration of existing construction that will not result in any changes to the building footprint or height (if checked, this table does not need to be completed). Zoning District: Allowed/ Required Proposed Lot Area (sq. ft. and ac.) Front Setback Rear Setback Side Setback Side Setback Lake or Pond Setback Railroad Setback % of lot coverage by major buildings % of lot coverage by appurtenant structures Parking (# of spaces) Building Height (# of stories) Other (describe): 3 of 11 v

4 Sketch Plan Instructions: Applications for new construction, additions, fences, and walls must include a sketch plan. The sketch must be drawn to scale and should include, at minimum, the following elements: scale, north arrow, property lines, existing and proposed buildings, utilities, and required and proposed setbacks for all proposed structures. Sketch Plan 4 of 11 v

5 Occupancy and Size Form Instructions: Indicate the intended occupancy and whether it is new, an addition, or an alteration. Provide the square footage and height for all proposed new construction, additions, and alterations. Occupancy and Size Check all applicable Occupancy New Addition Alteration Finished basement Assembly (Group A) Business (Group B) Educational (Group E) Industrial (Group F) Institutional (Group I) Mercantile (Group M) One-Family Dwelling (Group R3) Two-Family Dwelling (Group R3) Multiple Dwelling Permanent Occupancy (Group R2) Multiple Dwelling Transient Occupancy (Group R1) Multiple Dwelling Residential Care (Group R4) Storage (Group S) Utility & Miscellaneous (Group U) Provide all measurements as applicable 1 st floor 2 nd floor Other Total sq. sq. ft. sq. ft. floor ft. Proposed height (ft. & in.) 5 of 11 v

6 Construction Checklist Instructions: The following form is only required for new single family dwellings. Indicate which elements are included with the application. Provide an explanation for any element not included. Checklist for New Single Family Construction and Additions Complete Building Permit Application Res Check Certificate (2-copies) Two (2) sets of construction plans with following elements: Floor plans Foundation plan Cross sections Elevations Window and door schedule Light and Ventilation requirements Egress Requirements Plans signed and sealed by registered architect or engineer Highway Work Permit Water/Sewer Tapping Permit Notes/Explanation Yes No N/A Instructions: The following form is required for multi-family and non-residential construction projects. Indicate which elements are included with the application. Provide an explanation for any element not included. Checklist for New Multi-family and Non-residential Construction and Additions Yes No N/A Complete Building Permit Application Com Check Certificate (2-copies) Two (2) sets of construction plans with following elements: Floor plans Foundation plan Cross sections Elevations Window and door schedule Light and Ventilation requirements Egress Requirements Design loads including floor, snow load, and wind load Seismic design Plans signed and sealed by registered architect or engineer Highway Work Permit Water/Sewer Tapping Permit Notes/Explanation 6 of 11 v

7 Property Owner Affidavit Form Instructions: The Property Owner Affidavit Form is required to be completed for all projects that require issuance of a decision or permit from the Village. Affidavit I (we),, being duly sworn, depose and say that I (we) am (are) the owner(s) of the property identified in the attached application and that the statements herein contained and the information provided in the attached plans and other exhibits are in all respects true and correct to the best of my (our) knowledge. I (we) also acknowledge that I (we) have received written instructions regarding the process for which I (we) am (are) applying. I also hold harmless the Village of Saranac Lake from any and all damages, judgments, costs or expenses that may be incurred by issuing this permit. I acknowledge that nothing contained herein, including any permit issued by the Village of Saranac Lake, shall be construed as an assertion of compliance with any requirements of the provisions of any State or Federal Agency that may have jurisdiction over the proposed project. The Village of Saranac Lake makes no representation pertaining to the applicant s compliance with any governmental laws, rules or regulations other than the Village of Saranac Lake Code and assumes no obligation for notification and coordination in connection therewith. The Village of Saranac Lake also makes no representation as to the existence of any other public right or the private rights of an individual or corporation with respect to a project. Property Owner Property Owner STATE OF ) ) ss.: COUNTY OF ) On the day of, 20, before me, the undersigned, personally appeared, personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person on behalf of which the individual(s) acted, executed the instrument. Notary Public 7 of 11 v

8 Agent Affidavit Form Instructions: Completion of this form is required when the applicant is not the owner of record of the property identified in the application. Authorization for Agent to Represent Owner I (we),, the owner(s) of the real property described in the attached application, do hereby authorize (name) to act as my (our) agent(s) and to represent me (us) regarding the attached application and to appear on my (our) behalf before any administrative or legislative body in the Village of Saranac Lake considering this application and to act in all respects as our agent in matters pertaining to the attached application. Property Owner Property Owner STATE OF ) ) ss.: COUNTY OF ) On the day of, 20, before me, the undersigned, personally appeared, personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person on behalf of which the individual(s) acted, executed the instrument. Notary Public 8 of 11 v

9 Insurance Information Form Instructions: Proof of adequate Workers Compensation and Liability Insurance or exemptions are required for all building permits. Indicate which form will be submitted for each type of insurance. Then indicate whether the appropriate documentation is provided. If required documentation is not included, provide an explanation. No building permit application will be processed until all insurance information is submitted. For more information about how to show proof of insurance, please refer to the Building Permit Information Packet. Insurance Check one for each type of insurance Certificate of Workers Compensation Insurance (contractors with employees) Certificate of Attestation of Exemption (contractors with NO employees) Affidavit of Exemption (homeowner performing work/ owner-occupied) Notes: NYSIF CE 200 BP 1 (attached) Workers Compensation Type of Insurance Liability 9 of 11 v

10 Affidavit of Exemption to Show Specific Proof of Workers Compensation Insurance Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence **This form cannot be used to waive the workers compensation rights or obligations of any party.** Under penalty of perjury, I certify that I am the owner of the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit that I am applying for, and I am not required to show specific proof of workers compensation insurance coverage for such residence because (please check the appropriate box): I am performing all the work for which the building permit was issued. I am not hiring, paying or compensating in any way, the individual(s) that is(are) performing all the work for which the building permit was issued or helping me perform such work. I have a homeowners insurance policy that is currently in effect and covers the property listed on the attached building permit AND am hiring or paying individuals a total of less than 40 hours per week (aggregate hours for all paid individuals on the jobsite) for which the building permit was issued. I also agree to either: acquire appropriate workers compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the NYS Workers Compensation Board to the government entity issuing the building permit if I need to hire or pay individuals a total of 40 hours or more per week (aggregate hours for all paid individuals on the jobsite) for work indicated on the building permit, or if appropriate, file a CE- 200 exemption form; OR have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit that I am applying for, provide appropriate proof of workers compensation coverage or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers Compensation Board to the government entity issuing the building permit if the project takes a total of 40 hours or more per week (aggregate hours for all paid individuals on the jobsite) for work indicated on the building permit. (Signature of Homeowner) (Homeowner s Name Printed) (Date Signed) Home Telephone Number Property Address that requires the building permit: Once notarized, this BP-1 form serves as an exemption for both workers compensation and disability benefits insurance coverage. BP-1 (12/08) NY-WCB 10 of 11 v

11 LAWS OF NEW YORK, 1998 CHAPTER 439 The general municipal law is amended by adding a new section 125 to read as follows: 125. ISSUANCE OF BUILDING PERMITS. NO CITY, TOWN OR VILLAGE SHALL ISSUE A BUILDING PERMIT WITHOUT OBTAINING FROM THE PERMIT APPLICANT EITHER: 1. PROOF DULY SUBSCRIBED THAT WORKERS COMPENSATION INSURANCE AND DISABILITY BENEFITS COVERAGE ISSUED BY AN INSURANCE CARRIER IN A FORM SATISFACTORY TO THE CHAIR OF THE WORKERS COMPENSATION BOARD AS PROVIDED FOR IN SECTION FIFTY-SEVEN OF THE WORKERS COMPENSATION LAW IS EFFECTIVE; OR 2. AN AFFIDAVIT THAT SUCH PERMIT APPLICANT HAS NOT ENGAGED AN EMPLOYER OR ANY EMPLOYEES AS THOSE TERMS ARE DEFINED IN SECTION TWO OF THE WORKERS COMPENSATION LAW TO PERFORM WORK RELATING TO SUCH BUILDING PERMIT. Implementing Section 125 of the General Municipal Law 1. General Contractors -- Business Owners and Certain Homeowners For businesses and certain homeowners listed as the general contractors on building permits, proof that they are in compliance with Section 57 of the Workers Compensation Law (WCL) is ONE of the following forms that indicate that they are: insured (C or U-26.3), self-insured (SI-12), or are exempt (CE-200), under the mandatory coverage provisions of the WCL. Any residence that is not a 1, 2, 3 or 4 Family, Owner-occupied Residence is considered a business (income or potential income property) and must prove compliance by filing one of the above forms. 2. Owner-occupied Residences For homeowners of a 1, 2, 3 or 4 Family, Owner-occupied Residence, proof of their exemption from the mandatory coverage provisions of the Workers Compensation Law when applying for a building permit is to file form BP-1. Form BP-1shall be filed if the homeowner of a 1, 2, 3 or 4 Family, Owner-occupied Residence is listed as the general contractor on the building permit, and the homeowner: is performing all the work for which the building permit was issued him/herself, is not hiring, paying or compensating in any way, the individual(s) that is(are) performing all the work for which the building permit was issued or helping the homeowner perform such work, or has a homeowner s insurance policy that is currently in effect and covers the property for which the building permit was issued AND the homeowner is hiring or paying individuals a total of less than 40 hours per week (aggregate hours for all paid individuals on the jobsite) for the work for which the building permit was issued. If the homeowner of a 1, 2, 3 or 4 Family, Owner-occupied Residence is hiring or paying individuals a total of 40 hours or MORE in any week (aggregate hours for all paid individuals on the jobsite) for the work for which the building permit was issued, then the homeowner may not file the Affidavit of Exemption form, BP-1(11/04), but shall either: BP-1 (12/08) Reverse acquire appropriate workers compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the NYS Workers Compensation Board to the government entity issuing the building permit (the C or U-26.3 form), OR have the general contractor, (performing the work on the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit) provide appropriate proof of workers compensation coverage, or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers Compensation Board to the government entity issuing the building permit of 11 v